Friday, August 21, 2009

A knight in shining armor, the anesthesiologist gallops away on his white horse after saving yet another lady from the throes of pain!

When the epidural works as it is supposed to this or a similar scene is what comes to mind. The fact that the anesthesiologist is the hero in this scenario doesn't bother me. Really, I'm not jealous! Even though un-scientific polls (conducted by me) show that most women would prefer to see their dentist rather than their gynecologist. I know that I will never experience a gyne exam but less popular than dental work? When I see my dentist I have what seems like a large and noisy Black & Decker drill excavating my tooth, shaking me to the core while flying debris land on my face and glasses. This all as I'm trying to watch Oprah on the tiny sized TV mounted high in the corner. It may be my only opportunity to learn what she is telling my patients to ask me. I'm not angry. I'm just sayin'!

Please ignore my digression. This post is not about exulting the virtues of epidurals but hopefully giving you an idea of what we know of it's benefits and disadvantages and perhaps dispelling some myths.

Lets start with benefits:

Epidurals have been shown to be more effective in relieving pain and have less of an effect on the baby than some of the intravenous medications. Their placement is usually easy and despite some women's fears not very painful. Depending on availability some may be able to walk with the epidural in place but in practice most women rest in bed. There is also the possibility of patient controlled epidurals where you control the amount of medication flowing through the pump.

Now disadvantages:

You may have heard that epidurals slow down the process of labor. This indeed appears to be true. Studies show that it can prolong labor by 40-90 minutes. There are also some conflicting data about the fact that it may increase the need for instrumental (vacuum or forceps) delivery.
A more common but usually minor risk is that epidurals can cause a headache. This commonly resolves within days and rarely requires an intervention called a "blood patch".

There are times that epidurals are ineffective or only partially effective. This does not happen very often but understandably can create a great deal of anxiety and panic. Some of my patients say that they want to be "drugged up" so they won't feel any pain. It is important to emphasize the other options for pain relief and provide tremendous coaching and support in case the epidural is unavailable or is ineffective.

How about myths:

Some of my patients make their minds up very early on that they will not consider an epidural under any circumstances. Unfortunately many times this is not a choice based on accurate information but rather myths perpetuated by friends and family members. One of the most prevalent is that epidurals cause chronic back pain. This has been shown not to be the case. The risk of developing back pain is the same whether you receive an epidural or not.

Another common but erroneous perception is that an epidural may not be placed until cervical dilatation has reached four centimeters. The view of ACOG (American College of Obstetricians and Gynecologists) is that "women in labor should not be required to reach 4–5 cm of cervical dilatation before receiving epidural analgesia".

Epidural analgesia is a safe and effective option for pain relief in labor. You need to approach this choice as you would any other medical procedure. Ask questions, discuss with your physician or midwife and consider the risks, benefits and other alternatives. This post is certainly not meant to be comprehensive but only to provide an overview and a starting point for discussion. In subsequent posts we will look at some other options to consider and they probably will not involve anesthesiologists or dentists!

Sunday, August 16, 2009

"A large number of women want to avoid pain. Some just don't fancy the pain [of childbirth]. More women should be prepared to withstand pain… pain in labour is a purposeful, useful thing…such as preparing a mother for the responsibility of nurturing a newborn baby," (Dr Denis Walsh-Associate Professor of Midwifery, United Kingdom, July 2009).
OMG! (Oh my god!) WITRMBSATITDAA?! (Who in their right mind believes such a thing in this day and age?)
I feel a little nervous starting a series of blogs about labor pain management. The discussion many times becomes overwhelmed by extremes of beliefs that accuse each other of often untrue and imagined practices. On one side are those that passionately advocate for natural, unmedicated labor and on the other those that believe medicalized pain relief is often the best choice for most women. The former at its extremes paints a picture of scalpel wielding, episiotomy cutting physicians who want to expedite delivery in time for the first “tee-off”. The latter on the other hand portrays an image of incense burning, oil rubbing midwives who would go beyond the boundaries of safety to achieve natural birth.
In my experience neither of these portrayals is anywhere near accurate. However it’s the extremes that grab the headlines and leave pregnant women confused and sometimes forced to choose sides.
Forgive my slight detour but this is very similar to our current debate on healthcare reform. If one listens to the loudest voices the choices are either granny killing death panels on one side or gun toting poor people haters on the other. The majority of us want to hear a reasonable mature discussion where all sides are heard and acknowledged, (I know people tell me I’m naive!).
Over the next couple of blogs I will discuss what options may be available to manage pain during labor. From medications and epidurals to meditation and guided imagery. Whatever pain management technique you may be drawn to, knowledge is empowering.
Some of my patients tell me that they are used to being in control and are fearful that they have none when it comes to pain in childbirth. In my opinion, control is a function of knowledge and together with your readings (but not googling at random!) and discussions with your healthcare provider team you will feel in charge. It is important for you and your healthcare provider team to have a “shared mental model”. This means that all of you agree on a common goal: a healthy baby with a healthy and happy mom.

Monday, August 10, 2009

We were two weeks away from her due date when my patient asked me how soon after the delivery she could start exercising again. It came as a bit of a surprise since up until that point my efforts to encourage physical activity had for the most part been ignored. She was concerned about losing her pregnancy weight.
We discussed that exercise after childbirth is safe and is important. The timing to some extent depends on the mode of delivery. That means whether the delivery was vaginal or through a cesarean section. Most physicians recommend six to eight weeks of recovery time after a cesarean section. After a vaginal delivery the timing depends on how the mother feels but probably two to four weeks after delivery would be reasonable. If the delivery happened to be complicated by tears or episiotomies then a discussion with the physician or the midwife is warranted.
Many women enjoy and relish the transformation that their bodies go through during pregnancy. Most of them however cannot wait to get back to their pre-pregnancy or even lower weight. That’s why I am asked a similar question quite a lot.
According to the Cochrane library review of the literature, weight retention after pregnancy can contribute to obesity. It is suggested that women who return to their pre-pregnancy weight by about six months have a lower risk of being overweight ten years later.
This review also indicates that probably a sensible approach would be to achieve this weight loss through a combination of diet and exercise.
Diet in this case does not mean severe calorie restriction. In order to see a sensible approach go to http://womenshealth.about.com/cs/breastfeeding/a/nursingdiet.htm .
Since my children were born I have tried to do something that doesn’t always come naturally. I have tried to exercise regularly and with a smile on my face! This is for the hope that they will see this as a normal part of daily living and not a torture to be endured either for health or weight loss.
I am a firm believer that starting your exercise routine in the postpartum period will help you reach your pre-pregnancy weight as well as act as a life lesson for your newborn.

Saturday, August 1, 2009

Our son was born on September 5th 2001 at 10pm and the next six weeks seemed much tougher than either one of us had expected.
I am an obstetrician and therefore used to being up at all times of the night. Prior to the arrival of my son I would dismiss comments such as “you better catch up on your sleep while you can”. After all I had been through a tough obstetric residency and how much worse could this really be.
My wife had to be induced and so we didn’t really sleep much the night before the delivery. We were just too excited. This would eventually add to our feeling of total exhaustion by the time our son was born. I clearly could not have been nearly as tired as my wife (before anybody comments that I wasn’t the one who carried and pushed the baby out!).
Our son was 8lbs 11oz and because of his size needed some supplementation with formula immediately after delivery. This was so that his blood sugar wouldn’t drop. My wife wanted to breast feed and I told her that this shouldn’t cause any problems. I was categorically contradicted in the morning by our nurse who told us that she could not breast feed since our son was used to the bottle now. Our son had “nipple confusion”. My wife burst into tears since we had clearly failed as parents and he wasn’t even a day old.
I was recruited to clear my son’s confusion. I had a syringe full of milk draped over my shoulder which was attached to capillary tubing. This tube rested on my pinky which was meant to imitate a nipple. Perhaps if I wasn’t as tired I would have protested a little more emphatically. As it was we kept trying and eventually were sent home.
The constant attention that the little person needed was shocking. Days and nights blended into each other and for the first couple of days neither one of us wanted to admit how overwhelmed we were. Then we felt guilty if we did acknowledge how hard this was. This would mean we were unfit parents. After all when you have your baby you are supposed to be overjoyed and walking around with a constant smile on your face. You know like the ones on the cover of magazines.
Thankfully at the same time I found a support group. Not an official one but a group of wonderful physicians who used to supervise residents with me one afternoon a week. They all had children of different ages and told me that neither our experience nor our feelings were unique. It was just unbelievable that no one talks more openly about how overwhelming being a new parent can be.
Since then I try not to forget to have a talk with first time parents before they deliver. I still see that look in the faces of many women when they come back to see me after the delivery. That pale and sleepy look. They tell me how tired and overwhelmed they feel but after every sentence remind me that they love their child. As if to make sure that I don’t judge them for complaining. I tell them our story and that they are not alone. I also recommend mom and baby support groups.
Sometimes the feelings of anxiety and sadness last beyond the first few days and weeks and that is the time to call your doctor or midwife to make sure you are not suffering from postpartum depression.
Our son is soon to be eight and we have a daughter who is five. It would be silly to try and find a word that describes how much we love them. We gladly work hard to take care of them and appreciate everyday what they have added to our lives. We also make sure to tell expecting parents that the first few weeks can be tough.